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Nosy - 20 - -Do r9Gh+ ii s s. F _ 01 <br /> '_ _ <br /> ApA Veatione RrWill Bol�rd WMn SuhmitteC Prr7party Completed, L O Sign The AppNEaudn, <br /> 7APPLICATION UNIT III <br /> ENVIRONMENTAL HEALTH PERMIT/SERV ..c.S <br /> y NOINCiA'S AND,OA IF VEHICLE INVOLVED,GIVE <br /> FLICANTS AND,CA loop 1sfAaL1ANMA47S,NOUSIN <br /> DNTAACIIOA ANO:On PUeUC POOLS,Yl4?E[1AMPu■a Make <br /> RORER ANC-OR RML tITATt INAPEpYtaNa Lic, No. ..�� <br /> If`NNS!ANGOR POULTRY RANCRtt ANe 9101MtLs qe I!L N0. <br /> YTAAt;CN MI2etLuttaus 191111`104g <br /> [Appncation DOIo��1190 v �nessiN o To Appear On Permit HARRIS_+QgIRUCTION <br /> Type PermiVServlc RR.U to 9LANM J?140 FE v..__.� _..�..... _, <br /> �IAR4 tONSIRUCTION - _---- <br /> IT <br /> , 15�� NN GHFSTfVUT _ <br /> IAP 1 tST(%1� � 9I�r ._�9 n rvwRw w_v Ad r• _ Em/riiQncy To sPhOM NO — <br /> Property Locat-cw- Arl rtiAA ._ <br /> Property Owner 5TH, JOSEPHS HC$PITTi„_ ,__.�„_____,,,_ Address 1$00 N. CA'IIFORNTT— <br /> , STOCKT <br /> •LODeretor'! Nemo . ___ __ _-__ __ _ Address -- <br /> T. FOOD E' TARLISHMENTS Total duildirg Sq. Fcotags FReltawanl, MaAlrnum Setting Capacity <br /> "'CI AgSTAURANT ' 0 FOOD V—APKET RE?AIL Er FOOD MARKET WHOLE. ,%L5 NEAT MARKET <br /> C] FOOD PROCESSiNI PLANT C3 C4MMlSSA8y Q ICE PLAIN' L7 BAKFSY <br /> O ROADSIDE FOOD S-rAND �' LIQUOR STORE 0 BAR O ITINERANT RESTAURANT <br /> ❑ CONFEGTIONAFY STORE FOOD SAL,vAOER CI PLOD DF,MONSTSAT:ON 0 FOOD VENDOR <br /> Cl VENDING MACHINES/No. 01 MOBILE FOOD "HEP. LNiT 13 VENw1NG VEkiC_E <br /> 13 FOOD CROP HARVPSTIN0/NO,Of Field Employees <br /> ALL APPLICANTS' Taint Employaei Including Operator& <br /> 2. HOUSING <br /> ',0'MOTEL/MOTEL/NO Of Unit! CEPTIF+CA',E OF OCCUPANOY <br /> �.G MOWLE NOME PARKINO o1$""a <br /> S, WATER QUALITY ❑ WATER SAMPLE (eactanall ❑ CHEMICAL <br /> PUSLIC WATER SYSTEM ❑ SURFACE WATLA SLFPLY ❑ WATER MAULER <br /> NO, OF PU$LlC Seft ED,(Connection) <br /> 4, RECFEATiONAL HEALTH , L3 SWIMMING POOL ❑ S"F L WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VRCTOR CONTROL, C1 POULTAY FARM/Maxlmum N:, O' 51rds <br /> r :ENNEUR nYlaya . /Amoral Population NO �..._. No.of Confining Cog** <br /> 'Sewage 0 aDas41 <br /> 9dfdwastoDsP0,18;M,e4r+c^_ <br /> WAIer SUPPly So.rCa Animal Waste 04p00a1 Method _.. .._.�- <br /> i. 0 CONSULTATION FEF, <br /> 7 PLAN CKPCKING FEE <br /> I. PEAL ESTATE <br /> P.E::' EST Water We I tnlliMllonC3 Semple❑ T:tls Company .-.... _-�....._... ---- — <br /> Sawage System Inspection 0 Address T41a. No. <br /> eKrow No <br /> seller M_.____ .-.—_.__ Seller Address <br /> Te!ephonoNa __.__r____^ Seller AgentNama <br /> Service ?'agre9t For Date <br /> horooy certify trial I neve prepared this applicailon and that the work will oe done In accordance with Stn J9sAwin County <br /> crv,nancvs, state taws, ano rulel and regVlattons of the San Joaquin Local Health Clew". <br /> APPLICANT'S SIGNATURE X _. .... --..__...—____ Title - bats <br /> FOA DEPARTMENT USE ONLV ` <br /> Fee Is Dust M A�',JJyU AIIr Q PER UkItT 0 Piz E B.0 EACH ❑ J46WrvN I A,RaGli.dd BY J•nwry 01 ❑ Jwiy I a Ap_•rvW eY Jury al_ <br /> `� 0u-u N0 REM+trANca ! 1 . neriT ' <br /> EASE E%PLANAT!pN AlOVN� DUC CN[Ct[0 <br /> I OA?E DAT! REMITTED AMOUNT <br /> EAE 1$52.50 4 hrs. overtime revie 10=5 210,00 <br /> 44.s�— ;$35.00 r hrs. 'r vi,_ _ �� <br /> PAORATiQN _ N�'` <br /> PLu} $6,21 AL� � — <br /> PEN LTY <br /> Rucwwe&Y Dila rLc•�c�NP ��. nrrmaNP. Y" "g'iYbMCa Date M:ilaa dai•aM <br /> ENYIRONM[NTAL nCALTF PERMIT iOES 1eP1 L.nAZELTON AVE,P.O.e•*9091 STOGATON,to"i <br />